The Emergency Department is The “New” Frontier of Public Health

I had always considered my field of expertise to be emergency medicine. I worked through the ranks as an emergency medical technician, then onward as a paramedic, which included a nine-year stint on a busy medical helicopter. I worked in disaster medicine, and was the associate director of a Harvard-affiliated disaster medicine fellowship in Boston. My current practice is as a nurse practitioner in a busy suburban emergency department (ED) and I am still active in emergency medical services as a SWAT medic and as an educator.

The emergency part of what I do is the exciting part —the part that stimulates the excitatory neurotransmitters that flood the brain, preparing it to act quickly and concisely.

We are selling ourselves short, however, when we label this role as “emergency” providers. Instead, “public health provider” is a much more appropriate term to use, because emergency departments and those who provide care there are really public health workers.

All of us who practice in emergency medicine know that real emergencies are few and far between. Our day-to-day is much more mundane. We deal with many urgent issues as well as some less urgent, primary care problems. We may even spend time filling printer paper or bringing a patient their lunch. We may help to find someone a homeless shelter, send a family home with warm coats for the kids, or pack up a bag with food and toiletries for a young girl we feel is being trafficked.

In light of all this, the purpose and the policies of the emergency department need to be redefined.

This is especially true in the midst of the devastation of the opioid epidemic.

The emergency department (ED) is often the first, and in many cases, the only contact with healthcare an individual with substance use disorder may have. The mindset of delivering care and the accompanying policies must shift towards a more public health view of the delivery of care from emergency departments. This would include shifting the care to include a longitudinal model of healthcare delivery with opportunities for outreach and continuity of care. There is certainly still a need for the ability to deliver expert emergency care, and that won’t and shouldn’t change.

There is however, also a need to redefine some aspects of emergency care delivery with a greater focus on the public impact these important institutions can have.

Harm reduction is a term that I previously had associated with seatbelts, bike helmets, and maybe even smoking cessation. I hadn’t really ever thought of it in the context of providing what are basically “tools for survival” in the opioid epidemic.

The ED has always been the place you go to when these mechanisms fail. Failure to wear your seatbelt, a good welt to the head after crashing your bike, or the ravages of emphysema brought on by years of smoking. This was true of the opioid epidemic as well. An overdose would come in, we would provide respiratory assistance, administer naloxone to revive them and then check their pockets and socks for any needles and drugs that could harm staff. After a period of observation, most of these people would be on their way, back on the street with a few pages of discharge instructions on the dangers of opioids.

We were doing our job, resuscitating them, feeding them and offering them help if they wanted it. These are all noble things.

There was a missed opportunity, however, to provide some additional steps that, while not necessarily a step towards recovery, could be vitally important in reducing risk for overdose and overdose death.

One such measure is making sure that every overdose leaves our doors with a dose of naloxone. At the very least their friends or families should have it. This is a little complicated because emergency departments are not dispensing pharmacies, and are not allowed to dispense medications, nor are hospital pharmacies supposed to fill ED prescriptions. The fact of the matter is, however, this is a drug that saves lives and anyone who needs it should get it.

There is a good opportunity here for policy change that would allow EDs to dispense naloxone. Quite frankly, it is already happening in practice. Changing policy would allow this to happen without having to skirt regulations.

It would also allow for the opportunity for federally or state-funded access to this medication, helping to defray the cost to the hospital and the patient. Providers should also be more proactive with prescribing naloxone to patients and to families and should consider including a prescription for naloxone any time an opioid is dispensed. Prescribing efforts have been less than optimal, occurring on average only 10 percent of the time providers discharge a patient after overdose. Efforts to improve naloxone access is an imperative, as is the policy change that is needed to implement it.

Needle exchange is another opportunity for EDs to impact this crisis. It is not something most of us are comfortable doing, but it is important that we change our mindset. Traditionally, if you come to the ED after an overdose, we do a search and remove any drugs — especially any needles. This is a safety measure, for us and for our patients.

We feel good once the needles are safely in the sharp box we perhaps mistakenly believe the patient, now without his or her “kit”, won’t be able to use again. That is not the case.

What happens more often is that needle-sharing occurs, putting the individual at risk for HIV, Hepatitis C and other issues. It’s important to dispose of the needles patients arrive with, as the safety of our care providers is paramount.

But, patients should leave with new needles, as well as alcohol preps, gauze pads, sterile water, and filter needles. This can be accompanied by a fact sheet on safe injecting, HIV, Hepatitis C as well as some resources for recovery.

This is also a good time to encourage using the “Buddy System”, making sure that no one ever uses alone, akin to the designated driver campaign for alcohol. Always having one sober individual can help decrease deaths and ensure access to help if needed.

Finally, medication assisted treatment is another option for EDs.

I prefer to call this just “treatment”, because in essence we are treating one disease just like any other disease.

The most commonly-used drug for this purpose is Suboxone. Without getting too deep into the pharmacology of this drug, it is an agonist-antagonist that helps to curb drug craving and withdrawal symptoms, but with less risk for overdose than pure agonists.

There is growing data regarding the effectiveness of Suboxone, with 1-year sobriety rates around 40 – 60 percent. This is really promising, yet access to this drug has been strictly regulated. In the United States, the treatment of opioid dependence with medications is governed by the Certification of Opioid Treatment Programs, 42 Code of Federal Regulations (CFR) 8. This act outlines access to Suboxone, specifically requiring providers to complete a training program as well as capping the number of patients a provider can treat.

This is a barrier to the ED, a place where many with opioid use disorder seek care. While some hospitals are tackling this issue, many lag behind. And prescribing the drug is just one step. There also a need for hospitals to be support services and treatment programs to support this initiative.

This is an area that requires some significant reform. Healthcare providers are, thankfully, pushing this forward. I hope this advocacy will lead to the development of best practices around this initiative.

The emergency department is a public health safety net. We see all sorts of problems and have to manage everything, from heart attacks and strokes, to getting someone a warm coat or a cab.

Emergency providers are frequently taking care of individuals with opioid use disorder, often right after an overdose. There is an imperative to use best practices and evidence-based interventions to ensure we are treating these people with dignity and with our best available treatments.

This includes access to naloxone, needle exchange, and a pathway that includes medication-assisted treatment with an opportunity for in- or out-patient treatment.

Policy needs to keep up with practice and needs to reflect simple public health measures that are proving to save lives.

Graphs (top) via Mass. Dept. of Public Health

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